Information Collection

Part D Drug Management Program

IC 264405 under ICR 202508-0938-023 · OMB 0938-1465.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10874 Part D Drug Management Program	Form
Form CMS-10874 Initial Notice Part D Drug Management Program	Form
Form CMS-10874 Second Notice Part D Drug Management Program	Form
Form CMS-10874 Alternate Second Notice Part D Drug Management Program	Form
Form CMS-10874 Model Prescriber Inquiry Letter Part D Drug Management Program	Form
Form CMS-10874 Model Sponsor Information Transfer Memorandum Part D Drug Management Program	Form
Instructions for Drug Management Program Notices.pdf	Instruction
Instructions for Drug Management Program Notices.pdf	Instruction
CMS-10874 Initial Notice Initial DMP Notice.pdf	Form
CMS-10874 Initial Notice Initial DMP Notice.pdf	Form
CMS-10874 Second Notice Corrected Second DMP Notice PDF.pdf	Form
CMS-10874 Second Notice Corrected Second DMP Notice PDF.pdf	Form
CMS-10874 Alternate Second Notice Alternate Second DMP Notice - clean 08.28.2005.docx	Form
CMS-10874 Alternate Second Notice Alternate Second DMP Notice - clean 08.28.2005.docx	Form
CMS-10874 Model Prescriber Inquiry Letter Model Prescriber Inquiry Letter.pdf	Form
CMS-10874 Model Prescriber Inquiry Letter Model Prescriber Inquiry Letter.pdf	Form
CMS-10874 Model Sponsor Information Transfer Memorandum Model Sponsor Information Transfer Memo.pdf	Form
CMS-10874 Model Sponsor Information Transfer Memorandum Model Sponsor Information Transfer Memo.pdf	Form
Part D Drug Management Program Crosswalk-Nonsubstantive Change 08.06.25.pdf Crosswalk: Alternate Second Notice	IC Document
Part D Drug Management Program Crosswalk-Nonsubstantive Change 08.06.25.pdf Crosswalk: Alternate Second Notice	IC Document
Alternate Second DMP Notice - track changes 08.28.2005.pdf Redline: Allternate Second Notice	IC Document
Alternate Second DMP Notice - track changes 08.28.2005.pdf Redline: Allternate Second Notice	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Part D Drug Management Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10874	Yes	Yes	Fillable Fileable
Form	CMS-10874	Yes	Yes	Fillable Fileable
Form	CMS-10874	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only
Form	CMS-10874	Yes	Yes	Fillable Fileable
Form	CMS-10874	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug System (MARx) System

FR Citation: 83 FR 6591

Number of Respondents: 319

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	62,248	62,248
Annual IC Time Burden (Hours)	152,585	152,585
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Alternate Second Notice		08/29/2025
Redline: Allternate Second Notice		08/29/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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